Case of Acute Paronychia in an Adolescent Following Recreational Lake Activities

Case at a Glance

A 12-year-old female presented with a rapidly progressing, painful, and swollen finger after a week of recreational activities at a lake. Initially diagnosed as a felon, the clinical presentation was more consistent with acute paronychia. Treatment was initiated with oral antibiotics and warm soaks.

Patient's Story

The patient is a 12-year-old female (height: 5'4", weight: 120 lbs) with a history of occasional nail-biting. She recently returned from a week-long stay at a lake, where her daily activities included digging for mussels in the sand and fishing, involving frequent contact with soil and worms. Two days prior to presentation, she began complaining of tenderness in one of her fingers. The symptoms progressed over the next 48 hours to include significant redness, swelling, and localized warmth.

Initial Assessment

The patient presented to an urgent care clinic on a Saturday evening. On physical examination, the affected finger was markedly erythematous, edematous, and warm to the touch. The inflammation and swelling were concentrated around the lateral nail fold. The patient reported significant tenderness on palpation. No visible cuts or breaks in the skin were observed. Her history of onychophagia (nail-biting) and recent environmental exposures at the lake were considered significant risk factors for a bacterial skin infection.

The Diagnostic Journey

Based on the acute presentation, the attending physician at the urgent care clinic made an initial diagnosis of a felon. However, the photographic evidence and description of symptoms—with inflammation localized to the nail fold rather than the fingertip pulp—were more characteristic of acute paronychia. A definitive culture was not obtained. The patient was instructed to begin a course of oral antibiotics and perform warm soaks.

Final Diagnosis

Acute Paronychia

Treatment Plan

The treatment plan initiated at the urgent care clinic consisted of:

1. Oral Antibiotics: Amoxicillin-clavulanate 875-125mg, one tablet taken twice daily.
2. Local Care: Warm Epsom salt soaks three times a day to reduce inflammation and encourage potential drainage.

Due to pharmacy hours, the first dose of antibiotics was delayed until the following day. The patient's mother reported an accidental missed dose on the second day of treatment, which was corrected thereafter. The patient found symptomatic relief from soaking the finger more frequently than prescribed (up to ten times a day).

Outcome and Follow-up

At the time of this report, the patient had taken three doses of her prescribed antibiotic. She was continuing with the medication and frequent warm soaks, which provided subjective pain relief. The family was advised to monitor the finger for the formation of a drainable abscess (pus collection) or any worsening of symptoms, such as spreading redness or increased pain. Follow-up with a primary care provider or return to urgent care was recommended if the infection did not show signs of improvement within the next 24-48 hours, as incision and drainage might become necessary.